Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

BACKGROUND

A factor-based coagulation management following major trauma is recommended as standard of care by the European Trauma Treatment Guidelines. However, concerns about the thromboembolic risk of this approach are still prevalent. Our study therefore aims to assess if such a haemostatic management is associated with an increased risk for thromboembolic events.

METHODS

In this retrospective observational study carried out at the University Hospital Zurich we compared two three-year periods before (period 1: 2005-2007) and after (period 2: 2012-2014) implementation of a factor-based coagulation algorithm. We included all adult patients following major trauma primarily admitted to the University Hospital Zurich. Thromboembolic events were defined as a new in-hospital appearance of any peripheral thrombosis, arterial embolism, pulmonary embolism, stroke or myocardial infarction. A logistic regression was performed to investigate the association of thromboembolic events with possible confounders such as age, sex, specific Abbreviated Injury Scale (AIS) subgroups, allogeneic blood products, and the coagulation management.

RESULTS

Out of 1138 patients, 772 met the inclusion criteria: 344 patients in period 1 and 428 patients in period 2. Thromboembolic events were present in 25 patients (7.3%) of period 1 and in 42 patients (9.8%) of period 2 (raw OR 1.39, 95% CI 0.83 to 2.33, p = 0.21). Only AIS extremities (adjusted OR 1.26, 95% CI 1.05 to 1.52, p = 0.015) and exposure to allogeneic blood products (adjusted OR 2.39, 95% CI 1.33 to 4.30, p = 0.004) were independently associated with thromboembolic events in the logistic regression, but the factor-based coagulation management was not (adjusted OR 1.60, 95% CI 0.90-2.86, p = 0.11).

CONCLUSION

There is no evidence that a goal-directed, factor-based coagulation management is associated with an increased risk for thromboembolic events following major trauma.

Incidence and risk factors for traumatic intraocular pressure elevation and traumatic glaucoma after open-globe injury

PURPOSE

To examine traumatic intraocular pressure (IOP) elevation and glaucoma after open-globe injury.

DESIGN

Retrospective, observational case series.

METHODS

Review of patients with open-globe repair at the University of Washington from May 1997 through July 2010. Traumatic IOP elevation and glaucoma were defined respectively as intraocular pressure (IOP) ≥22 mm Hg at >1 visit or need for glaucoma medication, and long-term (at least 3 months) glaucoma medication use or glaucoma surgery.

RESULTS

We included 515 eyes (515 patients). The mean follow-up was 12.6±20.1 months. One hundred twenty eyes (23.3%) developed traumatic IOP elevation, of which 32 (6.2%) developed glaucoma; six eyes (1.2%) required glaucoma surgery. The mean time to development of traumatic IOP elevation was 1.5±3.4 months (range 1 day to 2 years). Kaplan-Meier 6- and 12-month estimates for development of traumatic IOP elevation were 27.2 and 32.4%, respectively, and for development of traumatic glaucoma were 7.1 and 11.0%, respectively. Multivariate regression revealed associations between traumatic IOP elevation and older age, and traumatic glaucoma and prior penetrating keratoplasty, initial vitreous hemorrhage, Zone II injury, and penetrating keratoplasty after open-globe repair. Traumatic glaucoma was controlled (IOP <22 mm Hg) in 78.1% of eyes at final follow-up, with mean IOP of 18.2 mm Hg on 1.7 medications.

CONCLUSIONS

Traumatic IOP elevation and glaucoma were common after visually salvageable open-globe injury. Most cases developed within 6 months, although longer follow-up remains important for case detection. Penetrating keratoplasty before or after repair, and vitreous hemorrhage were notable risk factors.

Determinants of the outcome of intrauterine insemination: analysis of outcomes of 9963 consecutive cycles

OBJECTIVE

Our aim was to determine which factors influence the effectiveness of intrauterine insemination.

STUDY DESIGN

This article is a retrospective statistical analysis of outcomes of 9963 consecutive intrauterine insemination cycles.

RESULTS

Patient age was the main determinant of pregnancy outcome (analysis of variance F ratio = 29, P <.0001), followed by the number of follicles at the time of intrauterine insemination (analysis of variance F ratio = 9, P <.0001) and sperm motility in the inseminate (analysis of variance F ratio = 4, P =.002). A total of 18.9% of all patients <26 years old conceived, compared with 13.9% of those 26-30 years old, 12.4% of those 31-35 years old, 11.1% of those 36-40 years old, 4.7% of those 41-45 years old, and 0.5% of patients >45 years old (P <.001). When analyzed by single years, ongoing pregnancy rates after intrauterine insemination remained high through age 32 years. Across all ages and causes of infertility, 7.6% of patients with 1 follicle at the time of intrauterine insemination conceived, compared with 10. 1% with 2, 14.0% with 4, and 16.9% with 6 follicles (P <.01). When ovulation occurred before intrauterine insemination (ie, no visible follicular structures), 4.6% of patients conceived. The likelihood of pregnancy was maximized when motile sperm numbers were >/=4 million and sperm motility was >/=60%. Differences in pregnancy outcomes between sperm processing options were related to differences in sperm motility after processing; use of methods incorporating motility enhancement with pentoxifylline and motile sperm concentration through silica gradients yielded the highest overall pregnancy rates.

CONCLUSION

When the results of ongoing retrospective analysis of intrauterine insemination outcomes are applied, overall intrauterine insemination pregnancy rates have increased from 5.8% per cycle in 1991 to 13.4% per cycle in 1996, during which time the average age of patients undergoing intrauterine insemination has increased from 36.1 (+/-0.2) to 39.2 (+/-0.1) years.

High concentration versus incremental induction of anesthesia with sevoflurane in children: a comparison of induction times, vital signs, and complications

STUDY OBJECTIVE

To compare sevoflurane induction times and complications in children during a high concentration, primed-circuit method and an incremental induction technique.

DESIGN

Randomized, prospective open-label study.

SETTING

Academic university hospital.

PATIENTS

40 unpremedicated ASA physical status I and II children age 4 months to 15 years undergoing elective surgical procedures with general anesthesia.

INTERVENTIONS

Patients were randomized to one of two study groups. In the high concentration group, the anesthesia circuit was primed with 8% sevoflurane in a 2:1 nitrous oxide:oxygen (N2O:O2) mixture. Patients breathed this gas mixture spontaneously until loss of the eyelash reflex. In the incremental group, the face mask was applied and 1% sevoflurane in a 2:1 N2O:O2 mixture was administered. In this group, the sevoflurane concentration was increased by 1% every 2 to 3 breaths. Gas flows of 6 L/min were administered to both groups during the study period. Following loss of the eyelash reflex, the sevoflurane concentration was decreased to 5% until a depth of anesthesia sufficient to start an intravenous catheter was achieved.

MEASUREMENTS AND MAIN RESULTS

Induction cooperation, induction time (face mask application to loss of the eyelash reflex), one-minute vital signs [blood pressure, heart rate, oxygen saturation via pulse oximetry (SpO2)], induction complications. Induction of anesthesia was faster in the high concentration group than in the incremental group (mean (SD) 42 (9) sec vs. 66 (12) sec, respectively; p < 0.001). Induction complications were minor and occurred with similar frequencies (4/20 patients vs. 3/20 patients). There were no significant intergroup heart rate, blood pressure, or SpO2 differences during induction. No patients required treatment for hypotension or bradycardia.

CONCLUSIONS

In healthy pediatric patients undergoing mask induction of general anesthesia with sevoflurane, the induction time can be significantly shortened without an increase in the frequency of airway or vital sign complications using a high concentration, primed circuit technique compared with a conventional, incremental induction method.

Fine needle aspiration biopsy of idiopathic retroperitoneal fibrosis

OBJECTIVE

To report three cases of idiopathic retroperitoneal fibrosis (IRF) diagnosed by fine needle aspiration (FNA) biopsy and confirmed by histologic examination. To our knowledge, this is the first report on the FNA findings in IRF.

STUDY DESIGN

Specimens were obtained under computed tomographic guidance using the standard technique. Half the smears were ethanol fixed and stained with Papanicolaou stain, and the other half were air dried and stained with Diff-Quik. A cell block was prepared in all cases.

RESULTS

Similar findings were seen in all three cases. The predominant elements were fibrous tissue and inflammatory cells, which occasionally occurred together but often were separate. The inflammatory cells were predominantly small lymphocytes, with occasional plasma cells, histiocytes and neutrophils. Smears from one case showed the inflammatory component only, but the cell block in all three cases showed both elements. The diagnosis of IRF was suggested in two of the three cases. All patients underwent laparotomy for diagnostic confirmation, and two had therapeutic resection of the lesion. Histologic material reflected the FNA findings, showing hyalinized fibrous tissue and an inflammatory cell infiltrate consisting of lymphocytes, plasma cells, histiocytes and neutrophils. No infection, arteritis or malignancy was present.

CONCLUSION

Although the FNA picture is nonspecific, in combination with clinical and radiologic findings it is highly suggestive of a diagnosis of IRF. A presumptive diagnosis allows a rational approach to further evaluation and therapy, which, in most cases, is an exploratory laparotomy with ureterolysis.

Angiogenesis in invasive squamous cell carcinoma of the lip: tumor vascularity is not an indicator of metastatic risk

BACKGROUND

Recent studies have shown that tumor growth beyond a certain size requires angiogenesis. Microvessel density has, moreover, correlated with metastatic risk in some tumors. Invasive squamous carcinoma (SCC) can develop in the epithelium of the lip and metastasize even when relatively small. This study investigates neovascularization and its relationship to metastatic risk in this tumor.

METHODS

All 41 primary SCCs of the lip diagnosed at our institution from 1960 to 1991 were immunostained for factor VIII. Microvessel grade (Mv) from 1+ to 4+ and the average number of vessel profiles (TMvD) in the highest density 200 x (0.785 mm2) and 400 x (0.196 mm2) microscopic fields were determined. TMvDs were compared with those of adjacent non-tumor tissue (NTMvD). Normalized counts (TMvDns) were calculated as TMvD/NTMvD. TMvDs and TMvDns of metastasizing (N = 10) and non-metastasizing (N = 31) tumors were compared (student t-test).

RESULTS

In all SCCs TMvDs exceeded NTMvDs (50 vs. 35 at 200 x, P = 0.0014, and 26 vs. 14 at 400 x, P < 0.0001). Metastasizing and non-metastasizing tumors did not, however, differ in Mv, TMvD, or TMvDn.

CONCLUSIONS

Angiogenesis develops, but is not quantitatively related to metastatic risk, in primary invasive squamous cell carcinoma of the lip.

Histologic correlates of metastasis in primary invasive squamous cell carcinoma of the lip

Clinical and histologic features of 44 invasive squamous cell carcinomas of the lip treated by surgical excision were correlated with metastases and survival. Age, diameter, ulceration, grade, depth of invasion, muscle invasion, mitotic rate, lymphatic-vascular invasion, and tumor infiltrating lymphocytes were evaluated. Two (4.5%) patients had local recurrence, 10 (23%) had metastases to cervical lymph nodes, and 2 (4.5%) died from complications of extensive spread in the neck. One patient with local recurrence had regional node metastases. Regional metastases were discovered at the time of (3 patients) or up to 21 (median 8) months after initial diagnosis, correlating with ulceration (P = 0.003), depth of invasion (P = 0.0001), and mitotic rate (P = 0.05) of the primary tumor. Depth exceeding 2.0 mm. was associated with metastasis (P = 0.028), and all carcinomas deeper than 6.0 mm. metastasized. Eight of the 10 patients with regional metastases had no further disease after treatment through the follow-up period (median 64 months). Both fatalities were older (median 81 years) men. These results underscore the metastatic potential of invasive squamous cell carcinoma of the lip. Histologic analysis of the primary lesion can be used to identify individuals at risk.

The use of surrogate gestational carriers for assisted reproductive technologies

OBJECTIVES

We determined the effect of embryo transfer, zygote intrafallopian transfer, and frozen embryo transfer on clinical outcomes after surrogate gestational transfers.

STUDY DESIGN

Prospective randomization was carried out.

RESULTS

Forty-five infertile couples were matched with a gestational surrogate carrier and underwent 81 cycles of embryo transfer with various assisted reproductive technologic procedures. Nineteen cycles produced a clinical pregnancy, with delivery in 15 of 81 cycles (18.5% live-birth rate). Fifteen of the 45 couples (33%) had a child from the surrogate gestational carrier program.

CONCLUSION

No significant differences in clinical outcome were observed on the basis of the type of procedure performed or the age of the patient.

Endometrial responses to various hormone replacement regimens in ovarian failure patients preparing for embryo donation

Various regimens are recommended for replacing sex steroids in ovarian failure patients attempting donor embryo transfer. We histologically assessed endometrial biopsies obtained on simulated cycle day 26 from functionally agonadal patients (n = 19) receiving hormone replacement according to three different regimens: Regimen 1, oral micronized estradiol (E2) 2 mg days 1-5, 4 mg days 6-9, 6 mg days 10-13, 4 mg days 14-28, with progesterone vaginal suppositories, 100 mg day 15 followed by 200 mg days 16-28; Regimen 2, oral micronized E2 1 mg days 1-5, 2 mg days 6-9, 6 mg days 10-13, 2 mg days 14-28, with progesterone vaginal suppositories, 100 mg day 15 followed by 200 mg days 16-28; Regimen 3: oral micronized E2 1 mg days 1-5, 2 mg days 6-9, 6 mg days 10-13, 2 mg days 14-28, progesterone 50 mg intramuscularly delivered day 15 followed by 100 mg intramuscularly days 16-28. Biopsies were interpreted according to Noyes criteria. While all regimens resulted in variable degrees of stromal pseudodecidualization, Regimen 1 biopsies uniformly demonstrated glandular abnormalities consistent with excessive estrogen stimulation. This included aberrant maturation, intraluminal papillary excrescences and variations in epithelium size and stratification. Regimen 2 biopsies were morphologically normal in most patients, yet many manifested minor variations in gland maturity. Only Regimen 3 biopsies were consistently normal on day 26 or slightly advanced in maturation. We conclude that endometrial morphology differs according to the hormone replacement preparation and route of administration.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of norethindrone on gonadotropin and ovarian steroid secretion when used for cycle programming during in vitro fertilization

Norethindrone (NET) has been used for cycle programming and may result in attenuated responses to controlled ovarian hyperstimulation. The effects of NET on gonadotropin secretion, its bioavailability to the ovary, and its effect on ovarian steroidogenesis in vivo and in vitro were assessed. Endogenous secretion of luteinizing hormone and follicle-stimulating hormone was attenuated by 59% and 50%, respectively, after 2 weeks of orally administered NET. Twelve hours after a single 10-mg oral dose, significant levels of NET were measured in samples of peripheral (8.8 +/- 1.9 ng/mL) and ovarian venous blood (10.5 +/- 3.1 ng/mL), follicular fluid (7.1 +/- 2.1 ng/mL), and homogenates of ovarian tissue (8.0 +/- 0.6 ng/g). Furthermore, NET was detectable in follicular fluid 2 weeks after its withdrawal (863 +/- 149 pg/mL). However, there were no effects of NET on follicular fluid levels of estradiol and progesterone in vivo or on luteinized granulosa cell steroidogenesis in vitro. We conclude that when used for cycle programming in in vitro fertilization, NET does not inhibit ovarian steroidogenesis but does affect the hypothalamic-pituitary axis.

Relative frequency of malignant parovarian tumors: should parovarian tumors be aspirated?

There is a paucity of information concerning the frequency of malignant parovarian tumors and how to diagnose them preoperatively. Our retrospective 10-year analysis showed that among 168 women with parovarian tumors, three had malignancy (2%). Our data and a literature review suggest that most malignancies occur in reproductive-age women with cysts over 5 cm containing internal papillary excrescences. It remains to be determined what the roles of ultrasound and cytology are in diagnosing malignancy.

Pregnancy outcome in women with müllerian duct anomalies

The outcomes of 186 pregnancies in 150 women with müllerian duct anomalies who delivered over an eight-year period were analyzed. The average birth weight was 2,919 g. Eighty-three percent of the deliveries were by cesarean section; malpresentation was the indication for 80% of those deliveries. The incidences of breech presentation and transverse lie were 61% and 11%, respectively. Delivery of preterm infants occurred in 25% of the pregnancies, and 12% were small for their gestational age. There were two sets of twins. A history of a previous preterm infant, recurrent abortion or a second-trimester loss was given by 13%, 9% and 59% of the patients, respectively. Of patients examined for renal anomalies, 11% had a defect, usually unilateral renal agenesis.

Steroidogenesis in porcine follicle cells cultured in serum-free media

The purpose of this study was to determine the steroid production of cultured porcine follicle cells grown in serum-free media. Theca cells (TC) and granulosa cells (GC) from large porcine follicles (greater than 8 mm) were dispersed and plated as monolayer cultures in serum-free media. Media were removed from the cultures at 3, 6, 12, 24, 48, 72, 96, and 120 h and assayed for estradiol, progesterone, testosterone and androstenedione. Both GC and TC were capable of producing progesterone, androgens and estradiol in serum-free media. GC were responsive to human chorionic gonadotropin and follicle-stimulating hormone while TC were only responsive to human chorionic gonadotropin. Growth factors, particularly insulin, appeared to enhance ovarian cells' steroidogenesis.

Computed tomography versus magnetic resonance imaging for the evaluation of suspected pituitary adenomas

The purpose of this study was to evaluate and compare thin-section magnetic resonance imaging (MRI) and high-resolution computed tomography (CT) in patients with suspected pituitary adenomas. Twenty-two patients (19 women and three men) with hyperprolactinemia (N = 16), increased growth hormone secretion (N = 2), increased corticotropin secretion (N = 1), and nonsecreting adenomas (N = 3) were studied with both contrast-enhanced, high-resolution CT scanning and thin-section MRI. Contrast-enhanced examinations consisted of contiguous 1.5-mm coronal sections during contrast infusion. The MRI examinations consisted of spin-echo T1- and T2-weighted sequences with a 2.5-3.0-mm slice thickness on the coronal and sagittal planes. Fourteen women had similar findings on CT and MRI (four macroadenomas, six microadenomas, one wide stalk, two empty sellas, and one normal study). The remaining eight subjects had conflicting results: CT findings were compatible with a microadenoma in all eight patients, whereas MRI detected one enlarged pituitary, two empty sellas (one with prolapse of the optic chiasm) without evidence of adenoma, and five normal examinations. Thus, both studies detected macroadenomas accurately, but CT was frequently unable to diagnose correctly an empty sella. Because patients with possible microadenomas were not submitted to surgery, the accuracy of either radiologic method cannot be assessed at this time. However, we suggest that MRI is superior to CT because of its inherently greater soft-tissue contrast, which allows clear visualization of the optic chiasm, optic nerves, cavernous sinuses, and carotid arteries.

Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy

This study was designed to compare prospectively the parameters of morbidity, cost, length of hospital stay, and fertility outcome after linear salpingostomy by laparoscopy versus laparotomy. Entry criteria included stable vital signs, hematocrit greater than 30%, age over 18 years, and desire for future fertility. All patients underwent diagnostic laparoscopy. Sixty patients with unruptured ectopic gestations of 5 cm or smaller were randomized to either laparoscopy (N = 30) or laparotomy (N = 30). Postoperative follow-up included serial measurements of serum beta-hCG titers at 3-day intervals and hysterosalpingography at 12 weeks. The laparoscopy and laparotomy groups were similar in age, height, weight, gravidity, gestational age, hematocrit, ectopic pregnancy size, and preoperative beta-hCG levels. The estimated blood loss was significantly (P less than .001) lower in patients undergoing laparoscopy, and was not affected by vasopressin injection. Two patients in the laparoscopy group required laparotomy for hemostasis, and two patients undergoing laparotomy had wound infection. One patient in each group had persistent trophoblastic activity. Baseline serum beta-hCG levels and the rate and magnitude of postoperative beta-hCG decline were similar in both groups. The length of hospital stay was significantly (P less than .001) shorter after laparoscopic salpingostomy (1.4 +/- 0.1 days) than after laparotomy (3.3 +/- 0.2 days). Postoperative hysterosalpingography showed patency of the involved tube in 16 of 20 (80%) and 17 of 19 (89%) of patients in the laparoscopy and laparotomy groups, respectively. Pregnancy rates were ten of 18 (56%) and 11 of 19 (58%) in these groups, respectively, and all pregnancies were conceived within 6 months of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased ATP inhibition of liver phosphofructokinase from genetically diabetic mice

Phosphofructokinase (ATP:D-fructose-6-phosphate 1-phosphotransferase, EC 2.7.1.11) was partially purified from the livers of genetically diabetic mice (C57BL/KsJ-db) and their lean littermates (C57BL/KsJ). These genetically diabetic mice have been shown to be hyperglucagonemic and to exhibit symptoms resembling those of maturity-onset diabetes in humans. Two isoenzymes of phosphofructokinase were obtained after DEAE-Sephadex chromatography of extracts of livers from either normal or diabetic animals. One of these isozymes, peak II, from the genetically diabetic mice was shown to be more sensitive to ATP inhibition at physiological pH than the peak II isozyme from the normal animals. In addition, the peak II isozyme from the diabetic mice exhibited decreased affinity for fructose 6-phosphate. The altered kinetic properties of phosphofructokinase from diabetic animals are markedly similar to those recently reported for liver phosphofructokinase isolated from normal animals after glucagon treatment. Our results suggest that increased glucagon levels in diabetes may lead to altered regulation of phosphofructokinase in this disease.